Crammer’s Corner

Feedback from GP trainees often suggests a dearth of cases for Clinical Skills Assessment (CSA) practise, especially within study groups. CSA books attempt to bridge this gap, but they need constant updating to ensure they are in tune with the latest treatment guidelines. In this article, Dr Kunal Chawathey explains how trainees can greatly improve their preparation for the CSA by generating their own scenarios based on actual consultations.

The Clinical Skills Assessment (CSA) aims to assess the GP trainee’s ability to conduct safe, structured consultations with emphasis on data gathering, interpersonal skills and clinical management. In order to become fluent and confident at delivering such high quality consultations one after another in the CSA (and indeed in daily practice), it is imperative to have a combination of daily patient encounters (with adequate reflection) and regular group study sessions.

Trainees’ perceptions

Many trainees report that they struggle to get enough practice cases for the CSA. There are CSA books with ready-made scenarios, but these are not exhaustive. Furthermore, these scenarios are often outdated as new guidelines are developed and new drugs approved for treatment. However, there are easy ways to address these issues and the key to success lies in your daily patient encounters.

In this article, we shall look at how trainees can identify cases for CSA preparation and develop them further. I will also discuss use of the ‘Sliding doors’ concept, which is essential to get a better understanding of the chosen clinical topic during group study.

The daily clinic

Your daily clinic is a gold mine for CSA preparation. Not only will you get ‘hands on’ experience, but you can also identify areas of educational need and cases to enable practising for the CSA. For instance, let’s imagine you saw a patient with sub-optimally treated high blood pressure (BP). He was taking 2.5 mg ramipril with recent home readings of about 135/100. You ensured his renal function was checked within the year and that he was compliant with his medication. You then increased the dose of ramipril to 5 mg and arranged for repeat renal function tests. You conclude that this was a ‘low challenge’ case and move on to see the next patient.

Could such a case appear in your CSA? Would this patient provide a prompt for further reading? Could this be a template for generating one or more cases for CSA practise? The answer is yes to all the above questions. Let us look into this further.

Exploring learning needs

If you dismissed this case as a straightforward scenario that did not generate further learning needs, it is possible that you have missed out on an opportunity to update yourself with the latest National Institute for Health and Care Excellence (NICE) guidance in management of hypertension! In addition to pharmaco-therapeutic intervention, did you consider opportunistic health promotion (Stott and Davies model)? Did you use the NO TEARS approach for medication review?

Even if you focused just on pharmacological aspects, did you consider if he needed an individualised blood pressure target? Are you aware of the concept of ‘dipping’? Do you know the peak time of action of ramipril? When would you expect maximum effect of the dose increase? How would you respond to a patient asking why ramipril should be taken in the evening? As you can see, even a seemingly straightforward presentation can be a great learning prompt.

Sliding doors

The sliding doors concept (from the 1998 movie, Sliding doors!) can be used to generate multiple case scenarios based on a particular theme. Let’s say, you decide to discuss hypertension in your study group. You could start off with the scenario based on the above consultation. This will set the scene for a general discussion, review of NICE guidelines, BP targets, drug monitoring, contraindications, drug interactions, etc.

Once your group is acquainted with the basics of hypertension management, add in variations and complexity to the scenarios. Consider the following variations on the theme to generate further CSA scenarios.

The patient gives a history of a dry cough since he was commenced on ramipril (managing side effects)

As you can see, we have generated six scenarios related just to ramipril initiation – each with a different sub-theme, including non-concordance with NICE guidance, a possible clinical contraindication and dealing with a patient’s specific concerns. You could generate more scenarios, for example a patient might present within a couple of days of starting ramipril with symptoms suggestive of angio-edema, or a week later with postural hypotension, or with a significant worsening of his renal function – all fairly standard presentations in general practice.

If you are pressed for time, you could discuss these possibilities, role play a couple of them and move on further down the hypertension guidelines with patients on two or more drugs, patients with co-morbidities such as diabetes, angina, etc. You could throw in confounding symptoms, such as cough with loss of weight and a strong history of smoking and assess the trainee’s risk management skills.

Ground rules for CSA practise

Keep the CSA study group size to 3–4 trainees

If you would like to contribute to Crammer’s Corner please contact us at editorialoffice@innovaitjournal.co.uk.